Mental and Behavioural Health Clinical Reference Group

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Jane Millar

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3798 View 17 Comment In discussion Comments enabled In the category: Undefined

I would be interested in any advice the CRG can provide on the following question which has been raised by one of our members countries:

The issue is around the terminology for substance use/misuse/abuse. At present there is inconsistency in this area of the terminology and we are keen to rationalise this to the most up to date clinical representation. In some instances misuse and abuse terms are used synonymously, attached to the same concept as below – in this instance Substance misuse is flagged in the terminology as the UK preferred description so a system would pick this up for display in the record:

image2017-12-12_16-2-30.png

In other instances these terms are used on separate distinct concepts:

conceptId1Description1conceptId2Description2
84758004Amphetamine abuse (disorder)428659002Amphetamine misuse (finding)
231462006Barbiturate abuse (disorder)428623008Barbiturate misuse (finding)
37344009Cannabis abuse (disorder)428823006Cannabis misuse (finding)
78267003Cocaine abuse (disorder)429782000Cocaine misuse (finding)


ICD-11, though still in Beta, seems to be proposing “harmful pattern of use of <substance>” (with ‘abuse’ as a narrower term) and <substance> dependence as distinct categories.

DSM-V , I believe has dropped the abuse and dependence descriptions (used in DSM IV) and uses ‘substance use disorders’ on a continuum of severity, mild, moderate, severe.

Advice sought from UK Clinical Lead for addictions who advised that ‘abuse’ is not used. Misuse, harmful use and dependence are clinically useful terms. Misuse is used as a collective term for the ICD-10 categories of ‘Harmful use’ and ‘dependence’. But the latter are used instead of misuse if referring to specific pathways of care as they are different clinical pathways.

Please could you include this on the agenda of your next call, 21 May if possible

Many thanks

Jane Millar, SNOMED International

Contributors (7)

17 Comments

  1. Piper Allyn Ranallo

    Thanks for posting Jane. I've added this to the agenda for May 21.


  2. Paul Amos

    Hi Piper,

    I am not sure that this issue has been fully resolved and implemented and in addition we have received an  enquiry regarding related terminology from our translation colleagues. The query is as follows:

    About a year back, we decided to link the Dutch term 'drug use' (literally: drug use, but refers only to recreational drugs, not medication) to 361055000 |Misuses drugs (finding)|, because of its synonym 'substance user' and the absence of a better match in Snomed. Unfortunately we have received feedback from several directions that not all recreational drug use is problematic or misuse. It is only problematic if it causes personal problems.

    307052004 |Illicit drug use (finding)| is no better because in the Netherlands, some of these drugs aren't even illegal. 424848002 |Recreational drug user (finding)| is an option, except that it is a child of 228366006 |Finding relating to drug misuse behavior (finding)| - so we'd still be calling it drug misuse.

    I think the problem is that the UK and USA on one side, and the Netherlands on the other, make different distinctions. For us, the misuse of medication (which might be prescribed, bought over-the-counter, or got off a third party) is an entirely different kettle of fish than the use of cocaine, heroine, cannabis or mushrooms, which you buy on the street or even in the shop. For the second category, it is worthwhile to denote whether someone is using them at all and you can distinguish 'normal' use from problematic use. For the second category, you only want to note the abuse.

    Whereas in Snomed, the two are lumped together under 'misuses drugs'. Any use of cannabis is per definition misuse. This leaves us with a problem... We could create a new concept, but the problem is that we would like a 'uses drugs' to be parent to the existing 361055000 |Misuses drugs (finding)| and that is impossible with the current set of attributes.

    In the current situation, I think we are best off choosing 424848002 |Recreational drug user (finding)| and ignoring that it is a child of misuses rather than a parent. But what do you recommend? Is this something we could start a content tracker on? I know the Netherlands have a rather special take on drugs, but we are not entirely unique either: are there other Snomed countries who have encounter similar problems with this branch?

    It would be helpful if this could be addressed in a similar way to the recent work on Hallucinations etc. so that we could make the appropriate changes for the next release - would you consider this to be a suitable project for the group?


    Many thanks

    Paul

  3. Piper Allyn Ranallo

    Yes,

    I will add this to the agenda for Mon 05 Nov. 

    Piper

  4. Matt Cordell

    Has there been any progress on this? I'm inclined to agree with the direction Netherlands is describing, and some of the existing modelling almost ties into discussions I've had elsewhere about "judgements" in SNOMED CT.

    Something like "Misuses drugs (finding)" could be something like "Recreationally uses prescription medications". ie. A medication (with a clinical intent) is being misused recreationally. I'm not sure about a patient using a medication incorrectly or for "off label" purposes. (though "prescription medications" varies between countries..., just as illicit does)

    My suggestion would be:

    • Many of the existing concepts are ambiguous.
    • a distinction for reason for use "medicinal" or "recreational" (others?)
    • an additional subtype of "problematic/harmful use"

    Extensions can localise the terms to align with local practices/intents.
    I'll reach out to some of our clinical leads in this space and see what else I can find.

    1. Piper Allyn Ranallo

      Thanks for your input Matt Cordell. 

      This is another content area where variation in cultural norms require international input. Let me pull up the documentation we created around this and post to the thread for broader discussion.

      Piper


  5. Anna Rossander

    I ran into this area during implementation work and can only agree that it would be great if this work was continued!

  6. Paul Amos

    Hi Piper Allyn Ranallo,

    I was wondering whether the group had been in a position to progress this any further? I have closed the original CRS ticket from Feikje Hielkema-Raadsveldand transferred the responsibility to this group. Obviously, if there are changes to the terminology required to address the outcome, I would be happy to assist.

    I have copied this to Jane Millar as it was Jane who originally posted the query.

    Many thanks

    Paul

  7. Piper Allyn Ranallo

    Hi Paul Amos,

    Unfortunately, we haven't done any further work on this. We did do a fair amount of preliminary research on definitions when we initially addressed the topic. We decided at that point we needed to find at least one SME who worked specifically in the substance abuse space. We have a meeting today and I will see if we can plan to engage someone with the expertise needed to join us on a near-future call.

    Piper

  8. Paul Amos

    Hi Piper Allyn Ranallo,

    Many thanks, i appreciate the difficulty of getting the specialists, especially given the current "crisis".

    Paul

  9. Paul Amos

    Hi Piper Allyn Ranallo,

    This topic seems to be increasing in priority for a number of our users. Please see below a further query from the New Zealand NRC

    "Very shortly NZ will hold a referendum on the use of Cannabis. In order to be prepared, we have been looking at what is currently in the SNOMED International edition. One of our GP representatives in our group has mentioned that they would not be keen to use the drug related terms that refer to abuse/abuser or misuse/misuser for someone that is a recreational / occasional user. We have found 'Recreational drug user (finding) 424848002', however this is a subtype of 'Finding relating to drug misuse behaviour (finding)' and we also found Occasional drug abuser (with a synonym of 'Occasional drug user') however this has a parent of 'Misuses drugs (finding)'.

    We are keen to understand what SNOMED International defines as abuse/misuse and what is the difference is between 'recreational' and 'occasional'. This will help us provide advice back to our GP representatives."

    Jane Millar , given the ongoing requirement to try and address content in this area I wondered whether you might be able to help Piper in her quest to find a suitable domain expert in this area.

    Many thanks, Paul

  10. Piper Allyn Ranallo

    Hi Paul Amos,

    I will add this to our short-list of priorities. One of the members of the CRG, Uma Vaidyanathan,has connections with SMEs in the area of substance use and abuse, and we are reaching out to them for input.

    Will keep you posted!

    Piper

    1. Darrel Regier

      I would suggest Debbi Hasin at Columbia and Charles O’Brien at Penn— both of whom have experience with the DSM-5 discussions. Since this is generated fro New Zealand, John Saunders from Australia, with extensive experience with both DSM-5 and ICD-11 substance use classifications could also be helpful.
      Darrel Regier

  11. Elaine Wooler

    Hi Piper Allyn Ranallo

    We have received another request which falls in the realm of this discussion.  Are we able to move this forwards again please?

    Many thanks

    Elaine

  12. Piper Allyn Ranallo

    Hi Elaine Wooler - Yes, let's do it.

    Darrel Regier - Thanks for the contacts. Do you have email addresses for these folks? You can email me directly at sven0018@umn.edu or pranallo@aan.com

    Thanks

    Piper


  13. Marie-Alexandra Lambot

    Hi,

    We need to create a refset in Belgium of the dependency concepts for the addiction FHIR resource/care set to share those data nationally and we need clear abuse concepts for the electronic patient summary. We have come across this issue of the distinction between abuse and misuse, which we do not understand in SNOMED CT. Are the word synonymous or not? If they are as it seems in places, what is the use case for the finding concepts where they seem to duplicate disorder equivalents? I see this issue dates back from 2018 and is critical for many. Is there now work in progress on this topic? If yes, how can we join the discussions?  If not, how can we help start that work? Thanks!

  14. Matt Cordell

    Just checking in on this one.

    We've had a request for some synonyms in this area for a small number of concepts.
    I've just actioned a most I'm plannign to add some synonyms/preferred term "<substance> use disorder" for "<substance> abuse (disorder)" concepts (a light touch and seems to align with the current language preferences, at least in Australia) - edit:I see some have been replaced with "harmful pattern of use...".
    But beyond that it starts introducing duplicates and ambiguity..

    References provided by the requester:

    1. Piper Allyn Ranallo

      Hi Matt,

      I like your idea of adding a preferred term that aligns with current nosologies and understanding of the disorders. I do think that's feasible for many of the existing concepts.

      As you mentioned, this is one of those areas where we have a lot of conflated concepts. These concepts required a much more substantial effort than we anticipated the CRG undertook the initial review  (it was clear that we needed a pretty extensive review this set of concepts in its entirety as there were not smaller subsets that we felt we could address by making simple changes).

      One important thing we realized we need to decide is whether to inactivate and recreate any substance use/ misuse concept with a SYN that suggests the disorder is an addiction or dependency OR whether we should just remove the inappropriate SYN?

      The idea of dependence is not part of the concept of use or misuse, so any description OR any relationship to an addiction/dependence concept suggests conflation of ideas.  Given how extensively these concepts are probably used, I worry about the effect of inactivating and recreating (although that's the approach that aligns with editorial guidance).

      In any case, could you share a document with the concepts to which each of the new preferred terms will be added once you've finalized the work?

      Best,

      Piper